First pass with Doximity with a custom note template, very pleased. Still requires some fine tuning but very few edits required. I also want to add a list of all the local doctors i refer to so it gets the names right.
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Generate an H&P or Progress Note according to the following rules.
GLOBAL RULES
• Write section headers in ALL CAPS.
• Omit unused sections.
• Do not include placeholders.
• HPI and Assessment must be prose.
• Plan must be bulleted using hyphens.
• Integrate relevant PMH, PSH, anticoagulation, diabetes, obesity, cardiopulmonary disease, neurologic disease, rheumatologic disease, and prior spine surgery into the HPI when clinically relevant to procedural candidacy.
• Integrate diagnostic review (MRI, CT, X-ray, EMG) into the Assessment rather than listing separately.
• Do NOT fabricate conservative care, imaging findings, or neurologic deficits.
• Do NOT include chronic opioid management language.
• Do NOT document stray symptoms that would conflict with the working diagnosis unless the clinician explicitly assigns them a separate diagnosis.
• Avoid documenting untreated radiculopathy when ordering facet procedures unless radicular pain is clearly not the primary generator.
• Do not list multiple competing pain generators unless explicitly assessed.
• Avoid including incidental imaging findings that could create payer confusion.
• If required medical necessity elements are not explicitly stated, do not fabricate them.
• Infer the type of visit (new patient or follow up) from the content of the discussion, and structure the level of detail accordingly.
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HISTORY OF PRESENT ILLNESS
Opening sentence must include, if available from conversation or context:
• Patient name, Age, and Sex
• Chief complaint
• Relevant comorbidities affecting intervention (diabetes, anticoagulation, CAD, COPD, CKD, osteoporosis, rheumatologic disease, prior spine surgery, obesity)
Narrative must include when stated:
• Onset and duration
• Location and laterality
• Radiation (only if clinically central)
• Character and severity
• Functional limitation (work, sleep, ADLs)
• Prior conservative therapy (PT duration, HEP, NSAIDs, neuropathic agents, injections, surgery)
• Response to prior injections (% relief and duration if stated)
• Anticoagulant use
• Smoking if relevant
• For obesity visits: weight trajectory, metabolic comorbidities, prior anti-obesity medications with exact doses and titrations.
Do NOT include imaging details here.
Preserve every medication name, dose, titration, and duration exactly as stated.
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PHYSICAL EXAM
Objective findings only.
Only include systems explicitly discussed.
No subjective language.
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ASSESSMENT AND PLAN
Begin with a synthesis paragraph including:
• Age/sex (if stated)
• Relevant comorbidities
• Most likely pain generator
• Imaging correlation
• Failure of conservative therapy
• Functional impairment
• Procedural candidacy
• Anticoagulation/steroid considerations
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PROCEDURE-SPECIFIC MEDICAL NECESSITY
Only include the relevant block for the procedure ordered.
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EPIDURAL STEROID INJECTION (ESI)
Include:
• Radicular pain in dermatomal distribution
• Imaging evidence of disc herniation, stenosis, or foraminal narrowing correlating with symptoms
• Failure of conservative therapy ≥4–6 weeks unless progressive neurologic deficit or severe pain due to disc herniation
• Functional limitation
Avoid:
• Pure axial pain without radicular features
• Mild imaging findings without clinical correlation
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MEDIAL BRANCH NERVE BLOCK (MBB)
Include:
• Chronic axial pain ≥3 months
• Pain localized to paraspinal region
• Failure of ≥6 weeks conservative therapy
• Imaging without dominant compressive nerve pathology
• No untreated radiculopathy
• Functional limitation
If prior block performed:
• Document % relief
• Duration of relief
• Correlation with anesthetic duration
Avoid documenting radicular symptoms unless explicitly determined not primary.
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RADIOFREQUENCY ABLATION (RFA)
Include:
• Two prior diagnostic MBBs with ≥80% pain relief (Medicare standard)
• Relief duration consistent with anesthetic
• Return of baseline pain
• Persistent facet-mediated pattern
• No new neurologic deficit
Avoid stating “mixed pain.”
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SACROILIAC JOINT INJECTION
Include:
• Pain localized below L5
• Positive provocative maneuvers if mentioned
• Failure of conservative therapy
• Imaging excluding alternate primary generator
• Prior diagnostic SI injection response if present
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SPINAL CORD STIMULATOR (SCS)
Include:
• Chronic neuropathic pain ≥6 months
• Failure of conservative therapy including medications, PT, and injections
• Prior spine surgery if applicable (post-laminectomy syndrome)
• Imaging excluding surgically correctable pathology
• Psychological clearance if discussed
• Functional impairment
• Trial stimulation planned with goal ≥50% pain reduction
Avoid documenting uncontrolled psychiatric disease unless explicitly assessed.
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INTRACEPT (Basivertebral Nerve Ablation)
Include:
• Chronic axial low back pain ≥6 months
• Failure of ≥6 months conservative therapy
• MRI evidence of Modic type 1 or 2 changes at treated levels
• Absence of significant radiculopathy
• No prior fusion at target level
• Functional limitation
Avoid documenting dominant disc herniation or compressive radiculopathy.
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STEROID RISK DOCUMENTATION
If diabetes present and steroid planned:
• Diabetes diagnosis
• Counseling regarding transient hyperglycemia
• Plan to monitor glucose
If anticoagulated:
• Anticoagulant name
• Peri-procedural management plan if discussed
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WORKERS’ COMP (MTUS / ODG STYLE)
When Workers’ Comp context present:
Include:
• Objective pathology correlating with symptoms
• Functional impairment affecting work
• Failure of conservative therapy
• Procedure consistent with evidence-based guidelines
• Expectation of functional improvement
Avoid speculative language.
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GENERAL MEDICAL NECESSITY (IF PAYER UNKNOWN)
Include:
• Chronicity ≥3 months
• Failure of conservative therapy ≥6 weeks
• Imaging correlation
• Functional limitation
• No contraindications
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OBESITY MEDICINE / COVERAGE-OPTIMIZED PRESCRIBING
Most local payers do NOT cover anti-obesity medications for obesity alone.
Prescribing logic:
If Type 2 Diabetes present:
• Use Mounjaro or Ozempic
• Document diabetes diagnosis
• Document HbA1c if stated
• Document prior metformin or other agents if mentioned
If Obstructive Sleep Apnea present:
• Use Zepbound
• Document OSA diagnosis
• Document CPAP intolerance or ongoing symptoms if discussed
If Established Coronary Artery Disease present:
• Use Wegovy
• Document CAD history (MI, stent, stroke, PAD if stated)
Avoid cosmetic or general weight-loss language.
Include:
• BMI if stated
• Weight-related comorbidities
• Prior weight loss attempts
• Absence of contraindications
• Lifestyle counseling if discussed
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PLAN FORMAT
After synthesis paragraph:
1. PROBLEM NAME
Brief reasoning paragraph.
• Schedule / Perform procedure (include level, laterality, approach)
• Manage anticoagulation if discussed
• Address glycemic considerations if steroid planned
• Continue conservative therapy if mentioned
2. Secondary Problem (if present)
3. Diabetes / OSA / CAD (if anti-obesity or GLP-1 prescribed)
Follow-up/Disposition:
State timing only. Omit if not discussed
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DENIAL AVOIDANCE SAFEGUARDS
The note must:
• Avoid documenting radiculopathy when performing facet procedures unless explicitly excluded as primary.
• Avoid listing incidental imaging findings.
• Avoid stating pain is “improved” without chronicity context.
• Avoid documenting multiple unclarified pain generators.
• Avoid vague or speculative terminology.
• Avoid including psychiatric or secondary gain language unless directly relevant.
• Avoid recording transient or irrelevant neurologic complaints that would reclassify the pain pattern unless clinician assigns a separate diagnosis.
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